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Inspection on 08/01/07 for Moor-haven (Nh) Limited

Also see our care home review for Moor-haven (Nh) Limited for more information

This inspection was carried out on 8th January 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Residents said that staff were friendly and helpful. One resident said, ""nothing is too much trouble" and another said " The staff are very nice. If I wasn`t happy I would mention it but I have no complaints at all". All the residents spoken to felt that Moor-Haven was a good place to live in and the atmosphere was warm and relaxed. The internal and external appearance of the home provides a clean, pleasant, comfortable environment for residents to live in. Residents liked their rooms and said the standard of cleaning was very good. The home employs an activities organiser who works with the residents to provide social events and leisure activities. Residents are treated as individuals and are asked to make suggestions about things they would like to do. Many of the residents were joining in with a quiz on the afternoon of the site visit and the atmosphere in the home was excellent with the residents chatting and bantering with each other. The activities organiser clearly knew all the residents very well and made sure everyone was included and able to join in. The home provides mainly home cooked food which all the residents spoken to said they liked. Everyone ate and enjoyed the lunch provided for them during the site visit. The manager makes sure that there are enough staff on duty to look after all the residents and well over 50% of care staff are trained to at least NVQ level 2, which means that staff have the skills and knowledge to deliver a high standard of care.The manager very often works alongside the nurses and carers and therefore is able to monitor that the care is given to a high standard. She is also well known to residents and visitors because of this presence.

What has improved since the last inspection?

Since the last inspection more staff have undertaken training in the prevention of abuse and when asked all were aware of what to do if they suspected abuse within the home.

What the care home could do better:

The residents` care files are kept electronically and copies of correspondence and paperwork from other sources are kept separately in a filing cabinet. Care plans and risk assessments were not kept up to date as well as they should have been and although all of the residents seemed well cared for, if an accurate record isn`t kept and reviewed in a consistent way there is a risk that some care needs may be overlooked or not met properly, or staff work in a different way and provide inconsistent care. The manager must accept that accurate recording is important in not only providing good care to residents, but in being able to demonstrate that good care is provided. Record keeping in general within the home is not seen as a priority and more attention is needed to make sure that all the records that are required by law are kept up to date and are accurate. The manager needs to develop a system whereby regular checks can be made to ensure that records are kept properly. The home also needs to make sure that the correct policies and procedures are followed when new staff are appointed to ensure that the proper checks are made to confirm that they are safe to work in the home before they start.

CARE HOMES FOR OLDER PEOPLE Moor-haven (Nh) Limited 193 Ripponden Road Oldham Lancashire OL1 4HR Lead Inspector Mrs Fiona Bryan Unannounced Inspection 8th January 2007 09:10 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Moor-haven (Nh) Limited DS0000025444.V325468.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Moor-haven (Nh) Limited DS0000025444.V325468.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Moor-haven (Nh) Limited Address 193 Ripponden Road Oldham Lancashire OL1 4HR Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0161 628 2064 0161 628 9801 Moor-Haven (NH) Limited Mrs Teresa Harwood Care Home 33 Category(ies) of Old age, not falling within any other category registration, with number (33), Physical disability (33), Physical disability of places over 65 years of age (33) Moor-haven (Nh) Limited DS0000025444.V325468.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 33 service users to include: *up to 33 service users in the category of OP (Old age not falling within any other category). *up to 33 service users in the category of PD (Physical disability). *up to 33 service users in the category of PD(E) (Physical disability over 65 years of age). No more than 24 service users to be admitted for nursing care. Two registered nurses to be on duty between 8am and 1pm. One registered nurse to be on duty between 1pm and 8am. The manager to be supernumerary for 9 hours per week. No more than one named service user under the age of 55 years may be admitted into the home. The service should at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 6th December 2005 2. 3. 4. 5. 6. 7. Date of last inspection Brief Description of the Service: Moor-Haven is a 33 bedded care home providing nursing care for up to 24 service users and personal care only for a further nine service users. The home is owned by a private partnership and is under the control of a manager who is also a registered nurse. Accommodation is provided over two floors, accessible by passenger lift. Eleven bedrooms are single with en-suite facilities. A further 20 single rooms are provided with hand washbasins. One double en-suite room is available for service users wishing to share. There is a lounge/dining room on the ground floor, with two further lounges, one of which is provided for service users wishing to smoke. On the first floor there is one lounge area. The home is situated in the Watershedding district of Oldham, close to local shops and on a main bus route. Moor-haven (Nh) Limited DS0000025444.V325468.R01.S.doc Version 5.2 Page 5 Fees for accommodation and care at the home range from £333 to £602 per week. Additional charges are also made for hairdressing, newspapers and personal toiletries. A service user guide is on display in the reception area of the home and a copy is given to all prospective residents. Moor-haven (Nh) Limited DS0000025444.V325468.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced inspection, which included a site visit took place on Monday 8th January 2007. Time was spent talking to residents and staff and observing the home’s routine and staff interaction with residents. Three residents were looked at in detail, looking at their experience of the home from their admission to the present day. A partial tour of the building was conducted and a selection of staff and residents’ records was examined including records of care, medication records, employment and training records and staff duty rotas. What the service does well: Residents said that staff were friendly and helpful. One resident said, ““nothing is too much trouble” and another said “ The staff are very nice. If I wasn’t happy I would mention it but I have no complaints at all”. All the residents spoken to felt that Moor-Haven was a good place to live in and the atmosphere was warm and relaxed. The internal and external appearance of the home provides a clean, pleasant, comfortable environment for residents to live in. Residents liked their rooms and said the standard of cleaning was very good. The home employs an activities organiser who works with the residents to provide social events and leisure activities. Residents are treated as individuals and are asked to make suggestions about things they would like to do. Many of the residents were joining in with a quiz on the afternoon of the site visit and the atmosphere in the home was excellent with the residents chatting and bantering with each other. The activities organiser clearly knew all the residents very well and made sure everyone was included and able to join in. The home provides mainly home cooked food which all the residents spoken to said they liked. Everyone ate and enjoyed the lunch provided for them during the site visit. The manager makes sure that there are enough staff on duty to look after all the residents and well over 50 of care staff are trained to at least NVQ level 2, which means that staff have the skills and knowledge to deliver a high standard of care. Moor-haven (Nh) Limited DS0000025444.V325468.R01.S.doc Version 5.2 Page 7 The manager very often works alongside the nurses and carers and therefore is able to monitor that the care is given to a high standard. She is also well known to residents and visitors because of this presence. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Moor-haven (Nh) Limited DS0000025444.V325468.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Moor-haven (Nh) Limited DS0000025444.V325468.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is adequate. Assessments had been undertaken prior to a prospective resident entering the home; however, more thought needs to be given as to how the assessments can be used to reflect individual preferences and social requirements so the home can be sure it can meet peoples’ diverse needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Assessments and care plans are held electronically with any correspondence or paperwork kept separately in a filing cabinet. Three residents were case tracked. All had assessments from social services provided. Moor-haven (Nh) Limited DS0000025444.V325468.R01.S.doc Version 5.2 Page 10 However, some of the information was not always transferred to the electronic record so these were incomplete in certain aspects, especially the sections related to the social background of the residents and their likes and dislikes etc. although it is accepted that most of this information is held in paper format. However by not including all the information on the electronic record, relevant information was not easily accessible for staff to consider when they were identifying care needs and formulating care plans; therefore some care needs did not have a corresponding care plans to address them. Nurses and care staff were knowledgeable about the needs of the residents and said that when a resident was admitted to the home they read and discussed the assessment. One resident had an unusual condition and information had been obtained from the internet about it for staff to read and gain a better understanding of the person’s care needs. Residents said they felt well cared for and that staff understood their needs. One resident who was quite new to the home said she felt that staff knew her preferred routine and allowed her to “carry on as usual” i.e. as she would have done if she had been at home. Intermediate care is not provided at Moor-Haven. Moor-haven (Nh) Limited DS0000025444.V325468.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is adequate. Care plans do not always provide staff with the information they need and care plans and risk assessments are not reviewed properly. Systems for monitoring the healthcare needs of residents are not consistent. This presents a risk that residents’ personal, health care or social needs may not be met. Personal support within the home is offered in such a way as to promote residents’ privacy and dignity. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Three residents were case tracked. Care plans were all kept electronically and provided incomplete information. Care plans were generalised and not personcentred and some care needs were not addressed, for example one resident had no care plan to assist staff to assess and monitor their pain although this was a significant problem. Moor-haven (Nh) Limited DS0000025444.V325468.R01.S.doc Version 5.2 Page 12 Risk assessments were not always dated and there was often no evidence that they had been reviewed. Where risks had been identified during the assessment there was not always a corresponding care plan. Care plans had not been reviewed monthly and were not up to date in their information. For example the nurse said that as the blood sugars for one of the residents had been stable they were only having random blood sugar tests a couple of times per week but their care plan stated that they were to have daily tests. Care plans did not always contain enough information, for example the care plan for one resident said they had a pressure mattress but did not specify what type of mattress or the correct pump setting. The pump was found to be set at the wrong pressure for the weight of the resident which could reduce or negate the effectiveness of the mattress, leaving the resident still at risk of getting pressure sores. The actions stated in care plans as being required were not always carried out in practice, for instance, most residents’ care plans stated that they should be weighed monthly, but in practice they were weighed approximately every 6-8 weeks. This included one resident who had been referred to the dietician for weight loss. The dietician had given advice about fortifying the resident’s food to increase their calorie intake and had advised that they were weighed monthly and their BMI calculated. This advice was found in the paperwork in the filing cabinet but was not on the electronic care plan. It was recorded that one resident had a wound that required dressing. Their care plan stated that the dressing was to be renewed “according to the dressing chart in the room”. Examination of this record showed that there was no description of the type of wound, no proper plan regarding the type of dressing required and no report about whether the wound was improving or deteriorating – there was mainly just a record that the dressing had been renewed. Also the record showed that the resident had another wound that was being dressed that was not mentioned on the care plan. Despite all the inconsistencies in the record keeping, at the time of the site visit the inspector could find no evidence that residents were not being cared for properly. Nurses and care staff were very knowledgeable about the residents’ care needs and likes and dislikes, and were aware of their current health status and any ongoing medical interventions that were taking place. All the residents looked well cared for and comfortable and said that their doctor was contacted if they were ill. Residents had confidence in the staff that they had the skills and knowledge to look after them well. Moor-haven (Nh) Limited DS0000025444.V325468.R01.S.doc Version 5.2 Page 13 However, the lack of detail in care plans and the erratic method of evaluating and reviewing risk assessments and care plans does leave the residents at risk that their health care needs may not be identified or met in a timely manner and does not provide the home with an audit trail to evidence the care that is given. The handling of medicines was generally satisfactory. Medicine administration records were up to date and controlled drugs were stored and recorded correctly. All the residents spoken to were very complimentary about the staff, saying that they were treated very well and felt at home and relaxed. Staff were able to give examples of ways in which they would maintain residents’ privacy and dignity. Interaction between staff and residents was professional, friendly and caring. Moor-haven (Nh) Limited DS0000025444.V325468.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. Although social care needs and preferences are not well recorded, the home does show a strong commitment to providing opportunities for social stimulation and interaction. Visitors are encouraged and welcomed into the home providing continued social contact. Flexible routines ensure that residents are able to exercise some choice in their daily lives. Dietary needs of residents are well catered for with a balanced and varied selection of food available that meets residents’ tastes and choices. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Three residents were case tracked. Minimal or no information was provided on each electronic record about the resident’s social history, circumstances and preferences and no resident had a care plan to address their social care needs. Moor-haven (Nh) Limited DS0000025444.V325468.R01.S.doc Version 5.2 Page 15 A print out of each resident’s assessment and care plan had been run off and was kept in their room and some of these contained a bit more information about individual preferences etc that had been added on by the person’s named nurse, although they were not completely up to date. An activities organiser works at the home for 25-30 hours per week and many of the residents engaged in a quiz during the afternoon of the site visit. The atmosphere was excellent and the residents and the activities organiser had a very good rapport and it was clear that they spent a lot of time together. During the quiz there was a lot of laughter and additional conversation and following this the residents were invited to put forward suggestions about possible trips they might take in the summer. After this group session the activities organiser went to spend some time on a one to one basis with some residents that did not want to or couldn’t join in with the group. One resident said “there is usually something going on” and another said staff always made sure his personal CD player was working as he spent a lot of time singing a long with his CD’s. Residents said that their visitors were made welcome and several residents said they went out with their families on occasion. Routines appeared to be flexible. For example, most of the residents ate a cooked meal at lunchtime but 2 residents had sandwiches. The nurse explained that this was because both these residents liked to get up late and have a late breakfast. This meant that they were not ready for a big meal at lunchtime so they had a sandwich then and their main meal at teatime. Lunch for the majority of residents was home made steak pie, carrots, cauliflower and mashed potatoes. All the residents said they were enjoying it and there was very little food wasted – the inspector thought one resident was going to clean the pattern off their plate!! A sample of the pie proved to be delicious, being full of meat and very tasty. Dessert was cheesecake and cream. One resident said his meal was lovely and said the food “is always really well cooked – like my mum used to do”. Several residents said how much they had enjoyed their Christmas dinner and said the home “did us proud”. One resident said she could have anything she wanted for breakfast and often had poached egg on toast. She went on to say “just think of anything and they’ll do it for you”. The majority of residents sat at the dining tables which were nicely laid with tablecloths, cutlery and matching crockery. The kitchen assistant served the tea and coffee and offered residents refills. Care staff assisted residents that needed help in a discreet manner. A pleasant relaxed atmosphere was in evidence that was conducive to residents enjoying their meal. Moor-haven (Nh) Limited DS0000025444.V325468.R01.S.doc Version 5.2 Page 16 The meal for the residents needing a soft diet could have been better presented as it was served in dessert bowls. The inspector was unsure if the carers mixed the separate components of the meal together whilst they were feeding the residents or whether it was provided like that from the kitchen but the result was that each mouthful of food would taste the same and the resident would not be able to taste the separate parts of the meal such as the meat and the vegetables. Moor-haven (Nh) Limited DS0000025444.V325468.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is adequate. Residents feel that their views are listened to and acted upon. Staff knowledge and understanding of adult protection issues provides a safe environment to protect residents from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: At the time of the site visit the manager said that the complaints policy was being reviewed and was waiting for advice from the Care Homes Association as to how it should be written. Residents said that they would be happy to raise any concerns with a member of staff and felt it would then be dealt with properly. One resident said she would mention any concerns to the manager but had “no complaints at all”. Staff said they would refer any complaint to the manager. An accident and incident record is maintained but no complaints had been received by the home since January 2006. Records showed that many of the staff had undertaken training in the prevention of abuse and safeguarding procedures and the manager said that this training would continue as a rolling programme. Moor-haven (Nh) Limited DS0000025444.V325468.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. The standard of the environment within the home is good, providing residents with an attractive and homely place to live in. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A partial tour of the home was undertaken. Communal rooms and bathrooms were homely, comfortable, clean and fresh smelling. Three spacious lounges and a further lounge/dining room provide ample space for residents to socialise and participate in activities. A range of armchairs was provided to meet the different needs of residents. Residents’ rooms were clean and tidy. The majority were personalised with the residents’ own ornaments, photographs and mementos. Moor-haven (Nh) Limited DS0000025444.V325468.R01.S.doc Version 5.2 Page 19 One resident said she liked her room because it was “nice and quiet” and she liked the view. A group of residents said that the home was always “spotless” and all said that the cleaners came to their rooms every day. One resident shared a double room with another resident. A privacy screen was provided. The manager reported that an inspection by the Fire Service had been undertaken on 5/1/07. The home had not yet received a copy of the fire report but the manager said she had been told that everything was in order but she needed to produce a written evacuation procedure, which she said she would do. An environmental health inspection took place on 13/7/06 when some minor recommendations were made that have been carried out. The home was in a good state of repair and was nicely decorated and maintained. Moor-haven (Nh) Limited DS0000025444.V325468.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is adequate. Staffing levels meet the needs of the residents. The home meets the standard for the percentage of care staff who have completed NVQ training. Recruitment procedures do not fully protect residents from abuse. Records did not provide evidence that all staff had received sufficient training to meet the needs of the service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Examination of the staff rota indicated that staffing levels are maintained appropriately. Staff and residents said that they felt there were usually enough staff to meet the needs of the residents. During the site visit nurse call bells were answered promptly and there were sufficient staff on duty. Of the 30 care staff employed at the home 20 have achieved NVQ level 2; of those 7 have also achieved NVQ level 3 and another 2 carers are undertaking the training. Four additional carers have commenced training for NVQ level 2. One carer has achieved NVQ level 4. Moor-haven (Nh) Limited DS0000025444.V325468.R01.S.doc Version 5.2 Page 21 Four staff personnel files were examined. Two domestic staff had started working at the home before their CRB disclosure certificates had been received. Neither of the 2 workers had regular contact with residents on their own or delivered personal care so POVA First checks had not been carried out. However, the administrator still seemed to be unclear about the need to obtain a POVA First for care staff if it is necessary for them to start work before their CRB is obtained, and reported that the umbrella body the home uses to apply for CRB’s was reluctant to send for POVA First checks. It is the responsibility of the registered provider to ensure that a check of the POVA register is made before a carer starts work at the home. One member of staff did not have a CRB certificate as the administrator said that it had been shredded. However, no record had been made of the date of issue or the reference number of the CRB so no evidence could be provided that a CRB had been obtained for the employee. Some employees had not provided the dates of their previous employment and there was no record on file that gaps in their employment history had been explored. Staff training records are kept electronically and showed that several staff had undertaken training in basic life support and anaphylaxis, infection control, prevention of abuse and dysphasia. A smaller number of staff had undertaken training in topics such as catheterisation, About 20 staff did not have any training for 2006 recorded. The manager said that the records were not entirely up to date which means that the home cannot fully evidence the training provided to staff in enhancing their skills. Two fire safety lectures had been arranged for January 2007. One domestic said she had not received moving and handling training or COSHH training. Another domestic who had started to do some care work had not yet received moving and handling training but said she thought it was coming up soon. The manager verified this. Moor-haven (Nh) Limited DS0000025444.V325468.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 37 and 38 Quality in this outcome area is adequate. The manager has the skills and knowledge to properly manage the home. Opportunities are provided for residents and their representatives to give feedback about how the home is meeting their needs. Residents’ financial interests are safeguarded. Record keeping needs to be improved to ensure the continuity of care and protection of service users. Health and safety policies and procedures protect residents. This judgement has been made using available evidence including a visit to this service. Moor-haven (Nh) Limited DS0000025444.V325468.R01.S.doc Version 5.2 Page 23 EVIDENCE: On the inspector’s arrival at the home for the site visit the manager was found working with the other nurses and carers, delivering care to the residents. The manager has a very “hands on “ approach and is well known to all residents and spends most of her time around and about the home. Staff and residents said that she was approachable and felt they could make suggestions about the routines of the home, or bring concerns to her attention. There have been no formal residents or relatives meetings for some time, but the activities organiser said that she often had chats with them during the course of an afternoon’s activities and this was seen by the inspector as described in the “Daily Life and Social Activity” section of this report. The administrator reported that most residents in the home are assisted with their finances by their families. Oldham MBC deals with the personal allowance for one resident and the money for this resident is paid into a separate bank account specifically set up for residents’ personal allowances. Invoices were available for all transactions. Sundry expenses are paid for by the company in advance and an invoice sent to the family. The maintenance person works for 10 hours per week and is responsible for health and safety checks of the building and equipment such as the emergency lighting, fire exits and water temperatures. A record was maintained of all these checks. Some staff said they had not received health and safety training in topics such as COSHH and moving and handling and the training records did not confirm that all mandatory training had been delivered to all staff. Accident records had been completed but the home had not been notifying the CSCI of reportable incidents. This was discussed with the manager who agreed to do so in future. Although standards of care within the home are good and the outcomes for residents in terms of their quality of life and experience of living in the home are good, the quality of the records kept at the home lowers the overall rating. Records that are not accurate and up to date and are not reviewed appropriately could lead to a risk to residents for example if their care needs are not evaluated effectively or staff training needs are not identified. The manager should develop a system to audit all the records and ensure that they are maintained to the required standard. Moor-haven (Nh) Limited DS0000025444.V325468.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable ENVIRONMENT CHOICE OF HOME Standard No Score 1 2 3 4 5 6 Standard No 19 20 21 22 23 24 25 26 Score X X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 4 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X 1 2 Moor-haven (Nh) Limited DS0000025444.V325468.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 Requirement Timescale for action 31/03/07 2. OP8 13 3. OP29 19 The registered person must ensure that residents care plans set out in detail the action that needs to be taken by staff to ensure all aspects of the health, personal and social care needs of the residents are met. Care plans must be clearly written, up to date and accurate and reviewed to reflect changing needs. (Timescale of 28/02/06 not met). The registered person must 31/03/07 ensure that risk assessments are reviewed and evaluated thoroughly and updated to reflect changing needs and current objectives for health and personal care. 28/02/07 The registered person must ensure that all information and documents stated in Schedule 2 of the Care Homes Regulations 2001 are obtained in respect of employees at the home. (POVA First checks must be done if the staff member needs to commence employment before their CRB has been received, and a full employment history must DS0000025444.V325468.R01.S.doc Version 5.2 Moor-haven (Nh) Limited Page 26 4. OP30 18 be recorded with a written explanation of any gaps in employment. (Timescale of 28/02/06) not met). The registered person must ensure that all staff receive training appropriate to the work they are to perform. (Staff must have training in moving and handling and COSHH). 31/03/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP3 Good Practice Recommendations The registered person should ensure that all information obtained during the assessment process is input onto the electronic system so that it is easily accessible when staff are reviewing care needs and care plans. The registered person should consider the presentation of soft diets to ensure that residents are able to taste the separate components of the meal. The registered person should ensure that the complaints policy is revised and displayed within the home for the information of residents and their representatives. The registered person should ensure that a record is made of CRB reference numbers and dates of issue before they are disposed of so that there is evidence that they were obtained. The registered person should ensure that a system of audit is set up to ensure that accurate records are maintained. 2. 3. 4 OP15 OP16 OP29 5 OP33 Moor-haven (Nh) Limited DS0000025444.V325468.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Ashton-under-Lyne Area Office 2nd Floor, Heritage Wharf Portland Place Ashton-u-Lyne Lancs OL7 0QD National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Moor-haven (Nh) Limited DS0000025444.V325468.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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